Treatment of midportion Achilles tendinopathy: an evidence-based overview

In Achilles tendinopathy, differentiation should be made between paratendinopathy, insertional- and midportion Achilles tendinopathy. Midportion Achilles tendinopathy is clinically characterized by a combination of pain and swelling at the affected site, with impaired performance as an important consequence. The treatment of midportion Achilles tendinopathy contains both non-surgical and surgical options. Eccentric exercise has shown to be an effective treatment modality. Promising results are demonstrated for extracorporeal shockwave therapy. In terms of the surgical treatment of midportion Achilles tendinopathy, no definite recommendations can be made. I

Surgical Treatment of Chronic Retrocalcaneal Bursitis

Purpose: The purpose of this systematic review was to analyze the results of surgical treatments for chronic retrocalcaneal bursitis (RB). Methods: Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, and the Cochrane Library (1945 to December 2010) were systematically searched for the following terms: calcaneal AND (prominence OR exostosis) OR ((retrocalcaneal OR calcan*) AND (burs* OR exosto* OR prominence)) OR Haglund[tw] OR Haglund's[tw] OR ((retrocalcaneal OR calcan*) AND (ostectom* OR osteotom* OR resect*)). Therapeutic studies on 10 or more subjects with RB were eligible. Quality was assessed by use of the GRADE scale and Downs and Black scale. Results: Of 876 reviewed abstracts, 15 trials met our inclusion criteria evaluating 547 procedures in 461 patients. Twelve trials reported an open surgical technique; three studies evaluated endoscopic techniques. Differences in patient satisfaction favored the endoscopic technique. The complication rate differed substantially, favoring endoscopic surgery over open surgery. Conclusions: There are many different surgical techniques to treat RB. Regardless of technique, resecting sufficient bone is essential for a good outcome. Even though the level of evidence of included studies is relatively low, it can be concluded that endoscopic surgery is superior to open intervention for RB. More evidence is a necessity to be more conclusive regarding the best surgical treatment. Level of Evidence: Level IV, systematic review of Level III and IV studie

Incidence of calcaneal apophysitis in the general population

Calcaneal apophysitis, or Sever's disease, is a traction apophysitis. It is a frequent cause of heel pain in children. Knowledge about the exact incidence of calcaneal apophysitis in the general population, however, is lacking. Cross-sectional study. From 34 general practices, records of patients between 6 and 17 years old, visiting the general practitioner (GP), were analysed. Diagnoses of calcaneal apophysitis were counted using computerised registration networks of GPs in 2008, 2009 and 2010. There were 16,383 SOAP files searched and a number of 61 children with calcaneal apophysitis were established over the years 2010, 2009 and 2008, showing an incidence of 3.7 in 1,000 registered patients. This is the first report on incidence rates of calcaneal apophysitis in general practice. With an incidence of 3.7 in 1,000 registered patients, it is a common pathologic entity, which requires more research on pathophysiology and therapy. The actual incidence may even be higher due the strict inclusion criteria of this stud

Open Versus Endoscopic Surgical Treatment of Posterior Ankle Impingement: A Meta-analysis

Background: Surgical treatment of symptomatic posterior ankle impingement consists of resection of the bony impediment and/or debridement of soft tissue. Historically, open techniques were used to perform surgery with good results. However, since the introduction of endoscopic techniques, advantages attributed to these techniques are shorter recovery time, fewer complications, and less pain. Purpose: The primary purpose was to determine whether endoscopic surgery for posterior ankle impingement was superior to open surgery in terms of functional outcome (American Orthopaedic Foot & Ankle Society [AOFAS] score). The secondary aim was to determine differences in return to full activity, patient satisfaction, and complications. Study Design: Systematic review and meta-analysis. Methods: MEDLINE, EMBASE (Classic), and CINAHL databases were searched. Publication characteristics, patient characteristics, surgical techniques, AOFAS scores, time to return to full activity, patient satisfaction, and complication rates were extracted. The AOFAS score was the primary outcome measure. Data were synthesized, and continuous outcome measures (postoperative AOFAS score and time to return to full activity) were pooled using a random-effects inverse variance method. Random-effects meta-analysis of proportions using continuity correction methods was performed to determine the proportion of patients who were satisfied and who experienced complications. Results: A total of 32 studies were included in this review. No statistically significant difference was found in postoperative AOFAS scores between open surgery (88.0; 95% CI, 82.1-94.4) and endoscopic surgery (94.4; 95% CI, 93.1-95.7). There was no difference in the proportion of patients who rated their satisfaction as good or excellent, 0.91 (95% CI, 0.86-0.96) versus 0.86 (95% CI, 0.79-0.94), respectively. No significant difference in time to return to activity was found, 10.8 weeks (95% CI, 7.4-15.9 weeks) versus 8.9 weeks (95% CI, 7.6-10.4 weeks), respectively. Pooled proportions of patients with postoperative complications were 0.15 (95% CI, 0.11-0.19) for open surgery versus 0.08 (95% CI, 0.05-0.14) for endoscopic surgery. Without the poor-quality studies, this difference was statistically significant for both total and minor complications, 0.24 (95% CI, 0.14-0.35) versus 0.02 (95% CI, 0.00-0.06) and 0.14 (95% CI, 0.09-0.20) versus 0.03 (95% CI, 0.01-0.05), respectively. Conclusion: We found no statistically significant difference in postoperative AOFAS scores, patient satisfaction, and return to preinjury level of activity between open and endoscopic techniques. The proportion of patients who experienced a minor complication was significantly lower with endoscopic treatment when studies of poor methodological quality were excluded

The appearance of the pre-Achilles fat pad after endoscopic calcaneoplasty

To evaluate whether the imaging features of the retrocalcaneal recess normalize on a conventional radiograph after surgery for retrocalcaneal bursitis and evaluate whether it can be reused if complaints reoccur. Patients who underwent an endoscopic calcaneoplasty at least 2 years before were eligible for inclusion. A lateral conventional radiograph of the surgically treated hindfoot was made to assess the retrocalcaneal recess and pre-Achilles fat pad; images were analysed, clinical complaints were registered and evaluated. Radiographs were evaluated by two experienced observers (one orthopaedic surgeon one musculoskeletal specialized radiologist), these scored the images either as "normal" (no obliteration of retrocalcaneal recess and pre-Achilles fat) or as "abnormal". Thirty patients (34 heels: 28 asymptomatic and 6 recurrent complaints) were included in this study. Observer one rated 12 images as "normal" (2 symptomatic heels and 10 asymptomatic), 22 "abnormal". Observer two rated 9 "normal" (1 symptomatic heels and 8 asymptomatic), 25 "abnormal". No correlation between the radiographic appearance and complaints (n.s.) was found. Cohen's kappa for interobserver agreement was low (0.11 n.s.). The appearance of the retrocalcaneal recess on a lateral radiograph cannot be used as a reliable diagnostic criterion for retrocalcaneal bursitis in patients who previously underwent endoscopic calcaneoplasty. This study clinical relevance is based upon the conclusion that a lateral radiograph cannot be used after endoscopic calcaneoplasty, whereas previous work reported the diagnostic value of a lateral radiograph for retrocalcaneal bursitis prior to surgery. II

Eponyms in elbow fracture surgery

Eponyms are common in medicine and in orthopaedic surgery. For future reference and historical considerations, we present common eponyms in elbow fracture surgery. We describe in short the biography of the name giver and give, where possible, the original description on which the eponym was based. Whether eponyms should continue to be used is a question that remains unanswered, but if we use them, knowledge of the original description can prevent confusion and knowledge of the historical background sheds light on the interesting roots of our professio

Prevalence of Os Trigonum on CT Imaging

The os trigonum is known as one of the main causes of posterior ankle impingement. In the literature, a wide variation of occurrence has been reported. All foot and/or ankle computed tomography (CT) scans made between January 2012 and December 2013 were reviewed. CT images were assessed, blinded for patient characteristics, for the presence of an os trigonum, size of the os trigonum, and type of os trigonum. In addition, the shape of the lateral tubercle of the posterior talar process was assessed. A total of 628 patients (1256 ankles) were included. In 32.5% of the patients of the cohort, an os trigonum was present. In 14.3% of these patients, it was present bilaterally. In a subgroup of patients without posterior ankle impingement the prevalence was 30.3%. Of the nonaffected ankles, an os trigonum was present in 23.7%. Patients with posterior ankle impingement were more likely to have an os trigonum (adjusted odds ratio [OR], 1.86). Afro-Caribbean/Surinamese/Central African origin was associated with a lower rate of occurrence of os trigonum (adjusted OR 0.43). In the ankles without an os trigonum, an enlarged lateral tubercle of the posterior talar process was found in 34.9% and 36.5% of the ankles. This study showed that os trigonum is a common accessory bone. With a prevalence of 30.3% in a population of patients with CT imaging of both ankles and 23.7% of the nonaffected ankles, the os trigonum is more common than previously reported. Patients with posterior ankle impingement complaints had a higher prevalence of an os trigonum. In one-third of the patients without an os trigonum, there was an enlarged lateral tubercle of the posterior talar process. Level III, retrospective comparative stud

High patient satisfaction and good long-term functional outcome after endoscopic calcaneoplasty in patients with retrocalcaneal bursitis

Purpose: The primary objective of this study was to determine the degree of patient satisfaction at a minimum of 5 years of follow-up after endoscopic calcaneoplasty. The secondary objectives were to assess functional outcome measures, pain scores, analysis of bone removal, reformation of exostosis at follow-up and correlation of the size of the exostosis and recurrent or persisting complaints. Methods: This study evaluated patients who underwent endoscopic calcaneoplasty, between January 1st 2000 and December 31st 2010, for the diagnosis of retrocalcaneal bursitis. The evaluation consisted of PROMs (patient-reported outcome measures), a questionnaire and a visit to the outpatient clinic for physical examination and a standard lateral weight-bearing radiograph of the ankle. Patient satisfaction, functional outcomes and pain scores were measured by use of a numeric rating scale (NRS). Size of the posterosuperior calcaneal exostosis was measured on a standard lateral weight-bearing radiograph using parallel pitch lines (PPL) and the Fowler–Philip angle (PFA). Results: The response rate was 28 out of 55 (51%) and the median time to follow-up was 101(IQR 88.5–131.8) months. The median satisfaction score for treatment results was 8.5 out of 10 (IQR 6–10). FAOS symptoms 84.5 (IQR 58.0–96.4), FAOS pain 90.3 (IQR 45.1–100.0), FAOS ADL 94.9 (IQR 58.1–100.0), FAOS sport 90.0 (IQR 36.3–100.0) and FAOS QOL 71.9 (IQR 37.5–93.8) and median AOFAS was 100 (IQR 89–100). The median PLL difference between before operation and 2 weeks after the operation was − 4 mm (IQR-6 and -1) and the median PLL difference between 2 weeks after the operation and at follow-up was 1 mm (0–2). The median PFA was 65 (63–69) at baseline, 66.5 (60.8–70.3) 2 weeks after the operation and 64 (60.8–65.3) at follow-up. Conclusion: Despite the limited response rate, this study shows high patient satisfaction and good long-term functional outcome in patients affected by retrocalcaneal bursitis who underwent endoscopic calcaneoplasty. Level of evidence: Level IV

Surgical treatment for posterior ankle impingement

This study aims to provide an overview of both the open and endoscopic procedures used to treat posterior ankle impingement, as well as an analysis, evaluation, and comparison of their outcomes. A systematic literature search of the Medline, Embase (Classic), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases and the Cochrane Database of Clinical and Randomized Controlled Trials was performed. Quality of included studies was assessed by use of the Downs and Black scale. After we reviewed 783 studies, 16 trials met the inclusion criteria. Of these trials, 6 reported on open surgical techniques and 10 evaluated endoscopic techniques. The complication rate (15.9% v 7.2%) and time to return to full activity (16.0 weeks v 11.3 weeks) differed between the 2 groups, both favoring endoscopic surgery. Although the level of evidence of the included studies is relatively low, it can be concluded that the endoscopic technique is superior to the open procedure. Level IV, systematic review of Level IV studie